8. Check One Box: Student has a disability which requires a special meal or accommodation. (Refer to definitions on reverse side of this form.) A licensed Medical Physician (M.D.), Physician Assistant (P.A.), Osteopathic Physician (D.O.), Advance Practice Registered Nurse (A.P.R.N.), Naturopathic Physician (N.D. or N.M.D.) must sign this form.

Student does not have a disability, but is requesting a special meal or accommodation due to food intolerance(s) or other medical reasons. Food preferences are not an appropriate use of this form. Schools and agencies participating in federal nutrition programs may accommodate reasonable requests. A licensed medical physician, physician’s assistant, registered nurse, nurse practitioner, or registered dietitian must sign this form.

The student does not have a disability. A fluid milk substitution is being requested for the student. Schools and agencies participating in federal nutrition programs may choose to accommodate this request by providing a USDA approved fluid milk substitute. A licensed medical physician, physician’s assistant, registered nurse, nurse practitioner, registered dietitian, parent, or guardian must sign this form.

9. State the disability or medical condition requiring a special meal, accommodation, or fluid milk substitute.

10. If student has a disability, provide a brief description of the major life activity affected by the disability.